A Badly Altered State

Attorney Kathleen Mullen has been fighting for the mentally ill homeless for fifteen years.Dr. Ed Casper believes the homeless are not getting the medical care they need.Sheryl Silver runs the Ruben L. Valdez Personal Care Center for the homeless and the mentally ill.Wade Livingston represents the state in court.

Last May, six homeless people sleeping outside the Denver City and County Building were awakened by the cops and arrested. They were there because city sweeps of the traditional homeless camping grounds along the South Platte River and Cherry Creek had forced them to migrate to Civic Center Park and sleep on the grates in front of city hall. Every night, dozens of them gathered around the building and set up a makeshift camp, creating a sad spectacle in front of Denver's symbol of municipal power.

After city workers and visitors complained about the resulting mess -- windowsills were used as outdoor toilets, trash and used needles littered the grounds -- the city cracked down. But no one was supposed to get arrested; Mayor Wellington Webb had insisted he was a friend of the homeless. Officials later claimed that two rookie cops had misunderstood their instructions and failed to call social workers who would have handled the evacuation in a more sensitive fashion.

And so the ragtag assortment of unbathed people with a habit of talking to themselves was escorted to the city jail, which often becomes a de facto homeless shelter. Since an estimated 50 percent of the homeless suffer from some kind of mental illness, including paranoid schizophrenia and other chronic conditions, it could also be said that the jail serves as an unofficial mental hospital.

That same month, just up the steps from where the six people were arrested, in a marble-clad courtroom, Denver District Court Judge Morris Hoffman was considering a case that directly pertained to their lives. For nearly twenty years, a class-action lawsuit on behalf of the chronically mentally ill has been making its way through the courts. It accuses the City of Denver and the State of Colorado of ignoring the plight of the homeless mentally ill and failing to provide them with adequate shelter and treatment. The suit is known as the Goebel case, after Ruth Ann Goebel, a mentally ill and homeless woman who died in a Denver alley in 1983, not far from a mental-health clinic that had recently discharged her.

Following years of squabbling, a settlement between the parties was reached in 1994. It called for Denver to provide housing for the mentally ill and for the state to provide treatment to the residents of that housing. Denver eventually met its commitment and purchased the housing, but the state failed to provide enough staff to allow many of the units to be filled, and dozens of them sat empty for years.

As a result, Denver attorney Kathleen Mullen, who has devoted more than fifteen years of her life to pursuing the case, returned to court and asked Judge Hoffman to find the state in contempt. Last fall, an angry Hoffman ruled that Colorado had not fulfilled its agreement to offer services to the homeless mentally ill in Denver, and he told the state to immediately meet those needs or face a contempt citation. In March, Hoffman followed up on his promise and found the state in contempt. Next week he will decide what action to take.

Mullen has asked the court to order Marva Hammons, director of the Colorado Department of Human Services, which supervises state mental-health services, to apply for a bed every night at a homeless shelter. If she finds shelter and thus displaces a homeless person, Mullen has asked that the state pay the cost of a hotel room for that homeless person. In addition, she requested that the state be fined $5,000 for every day it is not in compliance with the court order.

"Anyone who's the head of an agency who would allow 85 units of housing to lie fallow needs to feel what it's like for a chronically mentally ill person to be homeless," says Mullen. "That's why I want Marva Hammons to queue up at a homeless shelter."

During the past two decades, while hundreds of homeless mentally ill people slept underneath bridges and foraged through dumpsters in central Denver, the State of Colorado spent countless hours arguing in court that it was doing everything it could to help them.

The class-action lawsuit it was fighting was spurred by budget cuts in the early 1980s that closed several facilities for the mentally ill in downtown Denver and on Capitol Hill. It was filed in 1981 by several attorneys on behalf of an estimated 3,000 to 5,000 people with chronic mental illness living in central Denver. The plaintiffs charged that the services Colorado provided were inadequate and in violation of the Colorado Care and Treatment of the Mentally Ill Act, which says that those with severe mental illness are entitled to treatment. (After the lawsuit was filed, the state legislature amended that part of the law to add the words "subject to available appropriations.")

Like most states, Colorado once had an extensive network of state mental hospitals. In the 1970s, however, the introduction of psychiatric medicines led many to believe that the mentally ill could be discharged into the community, where a system of local mental-health centers could supervise their care. Fiscal conservatives saw this as an opportunity to save the state money, while civil libertarians uncomfortable with the fact that the state had the power to commit someone to an institution applauded the idea.

But the community mental-health centers never received enough funding to meet the needs of people who required constant monitoring. As hundreds were "deinstitutionalized," it soon became apparent that many were incapable of living on their own. Without mental hospitals, the most vulnerable were left to fend for themselves. Once they were on the streets, many failed to take their medication; others were prone to abuse alcohol and drugs. By the early 1980s, the sight of a homeless man or woman mumbling to themselves and pushing a cart full of possessions was a common one on the streets of downtown Denver.

The lawsuit contains a dozen brief biographies of such people and puts a human face on the abandonment of the mentally ill. The effects of the 1981 closure of a Capitol Hill day clinic for the mentally ill, for instance, are outlined in sorry detail: One man slips into alcoholism, another is thrown into jail, a third takes his own life. All three are repeatedly hospitalized for short periods of time at Fort Logan (the state's primary mental hospital) or Denver General Hospital (now Denver Health Medical Center), then discharged back onto the street.

The case first went to trial in 1982, and a district court judge found in favor of the plaintiffs in 1985. The state then began a series of appeals that reached all the way to the Colorado Supreme Court. The high court ruled in 1988 that the state could be required to take corrective action. In 1990 the state proposed a remedial plan, but legal skirmishes continued over whether the plan was adequate.

Weary of the endless litigation, all three parties eventually struck a deal in 1993, which was approved by the state Supreme Court in February 1994.

The 250-page settlement called for Colorado to boost spending for care of the chronically mentally ill in Denver by $7 million a year. The state agreed to target 1,600 people with severe problems, including those who were homeless, and the agreement spelled out in great detail exactly what services the state would provide through its contractor, the Mental Health Corporation of Denver (MHCD).

"The plan was to take 1,600 people and give them the services they need," says Mullen. "Case managers would go out to the community and track these people down, making sure they have a place to live, take their medication, get psychiatric support and vocational training." The homeless mentally ill were a priority under the plan.

The agreement also called for the City of Denver to provide 250 units of housing for the mentally ill, which it did only after much delay. The city purchased several homes in quiet residential neighborhoods for group housing and secured one hundred vouchers for subsidized apartments. The vouchers entitled people to live in Section 8 units, a federally subsidized housing program for the poor. The city now spends more than $2 million per year to fund the 250 housing units.

Once Denver found the housing, the state was supposed to pay for the care. But over the next few years, Mullen watched in frustration as perfectly good homes sat empty, waiting for staff. "They didn't have an explanation for why they'd let these units be empty when there was a desperate need," she says. "That they could allow wonderful homes to sit there empty says to me they've lost touch with the people they're supposed to be serving."

So she went back to court in 1997 to force the agreement.

For its part, the state continues to insist that it is meeting all the terms of the settlement, and in fact, many of the empty houses have been filled since Mullen went back to court three years ago.

"We pay about $17 million a year for services to the Goebel clients," says Wade Livingston, the assistant attorney general who represents the state in court. "Our position is that we exceeded [the settlement] terms in a lot of respects. I think our services meet all the legal requirements. Of course, they could always use more services."

Forcing Marva Hammons to stand in line for a bed at a homeless shelter won't solve the problem, either, he adds. "That doesn't seem to be a suggestion calculated to make anything better," he says. "Marva Hammons has a lot of hands-on experience dealing with people in need. The suggestion that she doesn't understand people in need is not fair."

Hammons headed up human-service agencies in Michigan and New York City before being appointed to her current post by Governor Bill Owens last year. Although Hammons was widely criticized in her previous jobs for endorsing budget cuts that may have played a role in the deaths of a six-year-old New York City girl and a Michigan social worker, she hasn't played a key role in the Goebel case, which has been going on since Dick Lamm was governor and throughout former governor Roy Romer's administration.

(Citing the upcoming hearing, a spokeswoman for Hammons referred all questions to Livingston.)

Judge Hoffman disagreed with Livingston's rosy assessment of the situation last spring when he held the state in contempt. For months before, Hoffman had made it clear that he was losing patience with Colorado's lackluster effort to fulfill its end of the bargain.

"It is puzzling to me that the State and MHCD seem to persist in the view that they are free to alter the terms of the settlement agreement unilaterally, as their own political and professional judgements dictate," the judge wrote in October 1999. "That is not how settlement agreements work, and that is not how this settlement agreement works. The parties to this litigation made their beds in the settlement agreement, and they are going to sleep there."

Hoffman scoffed at the state's skeletal staffing proposal for the group homes, calling it "woefully inadequate" and impractical. "The state asks me to require only three and one-half full-time employees per week," he wrote. "As I understand their proposal, one staff member is to be awake at all times. I have no idea how they propose to accomplish this with just three and one-half employees per week, unless they have people working double and triple shifts."

He also said the state had failed to give priority to the homeless in assigning people to the new housing, saying, "A big part of the problem is that MHCD has failed to develop any effective procedures to identify homeless class members."

The state's cavalier attitude toward filling the City of Denver's Section 8 subsidized apartments especially angered Hoffman, who noted that MHCD and the state had turned down the city's offer to put on special Section 8 orientations for the mentally ill and had failed to call the city to request more vouchers when they ran out.

"A Section 8 program like this one, if competently run, should have at least 90 percent of its certificates being used at any one time, the other 10 percent becoming unused as a result of ordinary renter turnover," wrote the judge. "Here, by contrast, eighteen months after Denver made these Section 8 certificates available, 25 percent of them have never been used. This is a scandalous and unacceptable situation."

Providing humane care for the mentally ill isn't impossible. Sheryl Silver does it every day.

Silver runs the Ruben L. Valdez Personal Care Center on 3636 W. Colfax Ave., a boardinghouse that was recently purchased by the Colorado Coalition for the Homeless. Since last summer, she and her staff have been caring for 85 people in the red-brick building, a former synagogue.

For years before the coalition took over, the building was used as a boardinghouse. But while the residents had a roof over their heads, virtually no services were provided, and Silver remembers being appalled by what she saw. "I brought someone here seven years ago and left crying," she says. "It was dark and depressing."

Today the Valdez center is known for the care it offers its residents, many of whom once lived on the streets. Every resident is assigned a case manager who comes up with an individualized plan that covers everything from medical care to vocational training. The case manager can also help residents apply for Social Security or Veterans Administration benefits and arrange psychiatric treatment or vocational training. Many of the residents have made enough progress that they're able to hold down jobs, including several who work at the 7-Eleven down the street.

"We're taking people right out of the streets or from shelters or prison," Silver says. "We try to make it as comfortable as possible for folks. We have people say, 'This is my family.'"

Most of the people living at Valdez have been abandoned by their real families, and their maladies range from schizophrenia to bipolar disorder to brain damage. After living on the street, they often arrive at the center with major medical problems and terrible self-esteem. "They have no feeling of self-worth when they come here," Silver says. "We try to overwhelm them with feelings of self-worth."

"When folks come here, their lives are in complete chaos," she adds. "We're helping them to organize their lives. We do a lot of crisis intervention."

Silver remembers one man who showed up in a taxicab wearing a hospital gown and with three toes recently amputated. Many have abused drugs and alcohol -- schizophrenics who are off their medication often turn to liquor when they start hearing voices -- and the staff has a program for substance abuse. "They say, 'I've never had anyone so involved with my business,' but they say it with a smile. A lot of them have never had anyone ask if they've had dinner."

A 75-year-old resident named Bobby comes up to greet Silver. She asks about the cowboy boots he's wearing. He just bought them at a thrift store, and she wants to make sure he can move his toes in them.

"You're looking quite dapper today," Silver tells him.

"I felt good all weekend," says Bobby, obviously flattered.

Their conversation is interrupted by the appearance of Stella, a mutt who spends her days at the home.

"Some of the folks who wouldn't talk will lay down on the floor and talk to her," says Silver. "Everybody loves Stella."

Residents are housed three to a room at the Valdez home. Meals are provided in a kitchen and dining room, and several residents help out with food preparation. Silver says that when the coalition took over the building, several residents hadn't been outside in years. An Eagle Scout troop built a garden in the center's backyard that's popular with the residents, and the staff now arranges field trips to Colorado Rockies games, concerts, even forays into the mountains. "The majority of people here don't have anyone except us," she says.

The remarkable change in the well-being of the Valdez residents shows what a caring staff supervising the mentally ill on a day-to-day basis can do. Unfortunately, the home has a perpetual waiting list, and Silver receives calls every day from social workers trying to place people there. She says the solution to the problem of the homeless mentally ill is right at her feet. "I don't think it's very complicated at all," she says. "We just need more places like this."

That, says Mullen, is exactly what the lawsuit is about. "The coalition for the homeless took a boarding home with no services and started helping them," she says. "Sheryl Silver is just the opposite of what I find when I'm working with the state."

But Livingston claims that as a result of the lawsuit, the state has spent millions to improve services for the mentally ill in Denver. He also says that almost all of the housing units provided by Denver are now full. The state is also paying for additional services like vocational training and a mobile crisis team. "Everybody agrees that things are better now than they were four years ago," he says. "Everybody agrees people fortunate enough to be in the Goebel class have much better services than people in other parts of the state."

An analysis prepared for the legislature's joint budget committee estimated that the state would spend an average of $8,480 per person per year on mental-health services for people in the Goebel class (under the settlement agreement, that covers 1,600 severely mentally ill people living in central Denver). And as Livingston pointed out, people in other parts of the state aren't so lucky. Those who are eligible for Medicaid receive an average of $3,255 per year in mental-health services, while people who don't quality for Medicaid receive a paltry $500 per year.

"There are ways to help people, but there needs to be the money to do it," adds Barbara Hancock, a boardmember of the Colorado chapter of the National Alliance for the Mentally Ill.

Colorado ranks 29th in the country for mental-health spending. Hancock says other states have found ways to get the mentally ill off the streets without reopening the state hospitals. Wisconsin pioneered a program known as Assertive Community Treatment, whereby a team of ten social workers takes responsibility for one hundred mentally ill people. Everyone on the team knows all the clients, and they work together to arrange housing, vocational training, medication, etc. The teams visit homeless shelters and look for people hanging out on the street, trying to win their confidence and bring them into the system -- a difficult task with paranoid schizophrenics. A network of "clubhouses" and drop-in centers provides a place for mentally ill people to go during the day.

"This is a way to help them connect," says Hancock. "This has been successful in keeping people out of the hospital and out of prison. There's a circle of support that needs to be there in the community for these people to survive."

Mary Boland, a vice president of Catholic Charities in Denver, has been involved in the Goebel case for several years. She served as a plaintiff's representative on an oversight committee created as part of the settlement, then resigned in frustration after a year, concluding that the state wasn't serious about its commitment.

"There wasn't a political will to enforce the terms of the contract," she says. "The state has chosen to keep contesting this. They've been doing this for fifteen years rather than rolling up their sleeves and putting this behind them. My sense is that Marva Hammons hopes this goes away."

Mullen has been involved in the Goebel case since its inception, when she was working in the Denver legal aid office. She helped draft the initial lawsuit with several other attorneys who were interested in the plight of the homeless mentally ill and took over as lead attorney in 1985. Now in private practice, she has continued to pursue the case, working on behalf of a group of people that she believes society has all but abandoned.

"These people can't speak for themselves," says Mullen. "This kind of treatment of this fragile population is intolerable."

Even though the court has ruled that Colorado failed to meets its obligations under the settlement agreement, the state has increased its services for mentally ill people in central Denver to some extent. More of them have a place to live and are receiving at least some type of treatment, thanks to the extra spending that grew out of the lawsuit. But those who have worked with the mentally ill for years say Colorado is still a long way from providing decent care for the population once housed in state facilities.

"It's a non-system right now," says Dr. Ed Casper, director of Behavioral Health at Denver Health Medical Center. "We get them in our emergency room, we get them in jail. There's no follow-up care and no system to support outpatients. There's no system of care for people who were in the state hospital."

Casper remembers when large numbers of the mentally ill were discharged from state hospitals in the 1970s, with promises that local mental-health centers would have the funding to care for them. "What was supposed to happen was, the money was supposed to follow the patient, but that money never made it to the community," he says. "They said all these services would be available in the community, but it didn't happen. We've taken apart the state hospital system and have not replaced it with anything."

The result is a pathetic stream of disturbed people who show up at hospital doors. "Every emergency department in the city gets inundated by mentally ill people," says Casper. "They may get stabilized, but there's nowhere to refer them. I saw a lady this morning who was placed on a waiting list [for treatment] last October. She said she called the suicide hotline and they said call back on Monday. There's no place for these people to even get medication."

Since Denver's homeless population is growing, Casper thinks the city is headed for even more trouble. "We've created an island of homeless mentally ill," he says. "If there isn't funding for emergency care, you're going to see the homeless situation get worse in the next two years. We're going to be facing a crisis."

However, it doesn't seem likely that the state legislature will substantially increase spending for mental-health care anytime soon. "It's a challenge to meet the needs for mental-health care because we're so restricted on the dollars we can spend because of the Tabor Amendment," says Representative Todd Saliman of Boulder, who sits on the Joint Budget Committee. He says that last year the legislature boosted mental-health spending by 8 percent, but he acknowledges that it isn't enough to meet the need. "I've long wanted to see community mental health funded properly," he says. "I just don't know where we'll find the dollars to do it."

That means that advocates for the mentally ill will continue to turn to the courts, trying to force the state's hand.

Mullen says it may take something as shocking as forcing a high-ranking state official to live in a homeless shelter to jolt the state out of its complacency.

"Marva Hammons and all the officials in the system have lost touch with the people they're supposed to be serving," she says.

Hammons's attorney isn't willing to guess how Judge Hoffman will reply to Mullen's unusual request. "I've been practicing law twenty years," he says, "and I've given up predicting what judges are going to do."